Continuity of Care

What is continuity of care in a Residential Aged Care and palliative care setting?

This is the process, by which all people who care for a resident are aware of the resident’s wishes and care needs and have the information they need to ensure the resident’s choices are respected.

The definition from the Department of Health (p216 [1]) states “Continuity of care refers to the aged care team member’s maintenance of knowledge about the resident and his / her family through consistent palliative practices to ensure that optimal staff, resident and family outcomes are achieved.

Continuity of care is optimised [2] by:

  • Reducing unnecessary hospital transfers
  • When transfers do occur, ensure beneficial treatments aren’t discontinued
  • Building relationships between:
    • staff of institutions
    • facility staff and families
    • visiting health care providers, members of the family and RAC staff.

Continuity of care can improve palliative care outcomes by:

  • Ensuring resident’s choices are respected
  • Avoiding burdensome, unwarranted interventions that do not improve quality of life
  • Better management of symptoms
  • Continuing support of family after resident’s death.

Measures that support continuity of care:

  • Timely recognition that a resident may be dying and sensitive discussions with resident (if capable) and family about changing care needs
  • Involvement of resident (if capable) and family in case conference with GP and RAC staff
  • Clearly documented and accessible advance care plans, including advance care directives
  • Documented goals of care
  • Use of an end-of-life care pathway (EoLCP)
  • Documented goals of care and EoLCP
  • Care plans that that include how to manage exacerbations of health conditions eg, heart failure, asthma
  • Access to after-hours pharmacy support when medication changes needed
  • An imprest system for drugs commonly used in terminal care
  • Good communication systems to ensure RAC staff and other health care providers are aware of new goals of care
  • Ensure that information is readily available to agency staff, locum GPs, paramedics and others who may be required to provide care without prior knowledge of the resident
  • Educational support for RAC staff and other health care providers to develop and maintain skills in palliative care.
  1. Australian Palliative Residential Aged Care (APRAC) Project. Guidelines for a Palliative Approach in Residential Aged Care Enhanced version - May 2006. Canberra: Commonwealth of Australia. 2006.
  2. van der Steen JT. Dying with dementia: what we know after more than a decade of research. J Alzheimers Dis. 2010;22(1):37-55.

Last updated 30 January 2017